Correct Answer: D

Rationale: The correct answer is D: Increased temperature. In thyroid storm, there is excessive thyroid hormone production leading to hyperthyroidism symptoms, including increased body temperature. Lethargy (
A) is more indicative of hypothyroidism. Hypotension (
B) is not a typical finding in thyroid storm; instead, hypertension is more common. Decreased heart rate (
C) is also not a common manifestation as tachycardia is typically present in thyroid storm.
Therefore, option D is the most appropriate manifestation to recognize in thyroid storm.

Correct Answer: A

Rationale: The correct answer is A: "Your breathing pattern causes this." The fluctuation in the fluid level of the water-seal chamber of a chest tube system is directly related to changes in intrathoracic pressure during breathing. As the client breathes in and out, the negative pressure in the pleural space increases and decreases, causing the fluid to rise and fall in the water-seal chamber. This movement is a normal physiological response and indicates proper functioning of the chest tube system.

Choices B, C, and D are incorrect because they do not accurately explain the reason for the fluid fluctuation in the water-seal chamber.
Choice B is incorrect as lung re-expansion does not directly cause the fluid movement.
Choice C is incorrect as high suction pressure does not cause this specific phenomenon.
Choice D is incorrect as fluid movement does not indicate an air leak.

Correct Answer: C

Rationale: The correct answer is C: Internal fixation of a fractured hip. Fat embolism syndrome (FES) typically occurs in long bone fractures or orthopedic surgeries like hip fixation due to fat droplets entering the bloodstream. These fat droplets can travel to the lungs, brain, and other organs, causing respiratory distress, neurological symptoms, and petechial rash. In contrast, choices A, B, and D are not associated with a high risk of FES. Thyroidectomy involves removal of the thyroid gland, repair of torn rotator cuff involves shoulder surgery, and tympanoplasty involves repairing the eardrum, none of which typically lead to fat embolism.

Correct Answer: C

Rationale: The correct answer is C: "I should wear goggles when irrigating a wound." This indicates an understanding of the teaching as goggles protect the eyes from splashes and sprays. Wearing goggles during wound irrigation helps prevent potential eye exposure to contaminated fluids, reducing the risk of infection.


Choice A is incorrect because wearing a gown to remove linens is unnecessary for personal protective equipment during this task.
Choice B is incorrect as sterile gloves are required for clean procedures like wound care, not for administering IM injections.
Choice D is incorrect because using both hands to recap a needle increases the risk of needle-stick injuries.

Correct Answer: A, B, D,E

Rationale: The correct actions for the nurse to take are A, B, D, and E. A - anticipating client prep for cardiac catheterization is important for timely intervention. B - assisting with a continuous heparin infusion helps prevent blood clot formation during the procedure. D - anticipating an increase in metoprolol dosage is necessary to manage cardiac workload during the procedure. E - obtaining a prescription for NPO status is crucial to prevent complications during the procedure.

Choices C (encouraging ambulation) and F (requesting an antibiotic prescription) are not directly related to preparing for cardiac catheterization and may not be necessary in this context.